I've been an eager observer of the annual announcement of Medicare ACO participants since I started helping organizations apply to join the Medicare Shared Savings Program (MSSP) in 2012. Here's why the 2018 list (which CMS recently posted on its website) is one of the most interesting ones I've seen:
1. Medicare ACO programs continue to grow—and MACRA was a major catalyst
This is the MSSP's 8th round of participants, yet there were still 124 new participants this year. There are now 561 MSSP ACOs (a 17% increase from 2017) and we're still waiting to hear about the expansion of Next Generation ACO Model.
Based on conversations I've had with health care leaders, MACRA played a major role in organizations deciding to join an ACO, either to get the 5% APM Bonus or to simplify MIPS reporting. I expect even more organizations in 2019 will join MSSP Track 1 to avoid the impact of the Cost category making up 30% of their overall MIPS performance score or will join one of the downside risk tracks in order to gain the 5% APM bonus.
2. There's a significant increase in downside risk ACOs
I expected a surge from the 42 organizations that had downside risk MSSP in 2017, since this was the first year for which ACOs had clear guidance on MACRA before making application decisions and CMS provided an attractive new option with MSSP Track 1+.
What I didn't expect was the sheer number of organizations that would pursue downside risk this year. The number of organizations taking on downside risk in 2018 increased to 101—up 140% from last year—with four ACOs joining MSSP Track 3 and 55 joining MSSP Track 1+. Given that Track 1+ does not provide an increased share of savings over the no-risk option of Track 1, I'm confident that the APM bonus played a key role in decision-making.
3. Organizations are jumping into risk without prior experience
It's not just that more providers are taking on downside risk—a number of organizations are also taking on downside risk without prior experience in a Medicare ACO program. For Cleveland Clinic to move to Track 1+ after generating $42 million in savings in 2016 makes a lot of sense to me. For the 21 organizations taking on downside risk in 2018 without prior ACO experience, I'm more concerned. If you look at the 2016 results, there were only two organizations without prior Medicare ACO experience that took on downside risk—and both lost millions of dollars.
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4. For-profit health systems are joining the program
With few exceptions (e.g. Tenet), most for-profit health systems have not joined Medicare ACOs. However, this year saw a major investment in ACOs from Community Health Systems, which created 15 ACOs for various markets. What remains to be seen is whether or not the incentives for joining an ACO under MACRA are significant enough for other large for-profit health systems to join in future years.
5. ACOs continue to be made up of multi-stakeholder collaborations
While collaboration is certainly not a new trend (some longstanding ACO participant organizations like Advocate are made up of more than 800 unique participants), the number of participating organizations per ACO has stayed high, with 37 organizations per ACO on average. In this latest round of ACOs, there are a number of organizations composed of multiple health systems such as Centrus Health, which is a collaboration between independent physician groups and the University of Kansas Health System, North Kansas City Hospital, and Shawnee Mission Health (part of Adventist Health System).
6. Early participants are going to be forced to take on risk
Unless regulatory guidance changes, you can be in the no-risk Track 1 of the MSSP for only two three-year periods. Twenty-nine of the organizations that started on or before 2013 have already moved to downside risk, but there are still 82 organizations in Track 1 that must decide if they are ready to take on downside risk next year—otherwise, they will be forced to leave the program.
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As value-based, risk-adjusted payment models become more prevalent, accurately identifying, documenting, and managing population complexity is critical. HCC codes reflect the conditions that contribute to total disease burden and are used by Medicare to determine reimbursement under value-based payment programs like MSSP, NextGen ACO, Medicare Advantage, and CPC+.
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